Healthcare Provider Details

I. General information

NPI: 1972826642
Provider Name (Legal Business Name): SHAGHAYEGH KAYMANESH D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 03/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14346 WARWICK BLVD #420
NEWPORT NEWS VA
23602-3814
US

IV. Provider business mailing address

14346 WARWICK BLVD #420
NEWPORT NEWS VA
23602-3814
US

V. Phone/Fax

Practice location:
  • Phone: 757-886-2096
  • Fax: 757-886-2097
Mailing address:
  • Phone: 757-886-2096
  • Fax: 757-886-2097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401412739
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: